Cancer

1. Use of the Oncology Beacon ® Module and VDW
Data to Identify Variations in Treatment and Cost
for Patients Diagnosed with Stage III/IV
Colorectal Cancer
18th Annual HMO Research Network Conference
May 1, 2012
Debra P. Ritzwoller
Institute for Health Research, Kaiser Permanente Colorado

2. Project Team
Co-Investigators: PMs:
KPNW: Mark Hornbrook, KPCO: Kimberly Bischoff
Maureen O’Keeffe-Rosetti KPNW: Jill Mesa
KPNC: Heather Clancy
KPNC: Larry Kushi
Programmer/Analysts:
KPCO: Tom Delate, Alex KPCO: Nikki Carroll, Capp
Menter, Jared Freml Luckett
KPNW: Mike Zimmerman,
Karen Riedlinger
KPNC: Karl Huang

3. Background
 Gaps exists in the literature related to the utilization
and costs of chemotherapy agents for colorectal
cancer (CRC) patients not captured by SEER-
Medicare data or clinical trials
 Key factors are needed
 Treatment intent (curative vs palliative)
 Use of evidence based protocols
 Dosing
 Treatment modifications and reasons for discontinuation
 Use of second-line treatment
 These data are now available from Epicare based
Oncology Beacon® modules that now populate
newly developed VDW infusion files

4. Aims
sing the wealth of cancer treatment data newly
available as a result of recent VDW infrastructure
development efforts associated with infusion and
chemotherapy utilization, in this PILOT project we…
xamine the factors associated with the receipt of
chemotherapy
xamine the variation in chemotherapy protocols and
regimens administered to patients with advanced CRC

5. Methods
• Using VDW Tumor Registry and Enrollment files at KPCO,
KPNC, and KPNW, we identified Stage III/IV CRC patients
diagnosed in 2010 - after Beacon implementation
 First diagnosed cancer
 Survived at least 1 month after diagnosis
 21 years of age and older
• Linked cases to
• VDW Demographics, Diagnosis, Census, pharmacy and procedure
files
• Infusion files derived from the Beacon modules
• 1st line Chemotherapy ascertained within 120 days of diagnosis
• Followed cases until death, disenrollment or end of 2011

6. Results
• 489 cases identified
• 46% stage III, 54% stage IV
• 47% < 65 years
• 9% Hispanic, 9% African American, 10%
Asian
• 83% had 6 or more comorbidities
• 68% (n=335) received chemotherapy
• 308 had identifiable chemotherapy regimens

7. Receipt of chemotherapy
• Was inversely related to
• Age
• Stage
• Number of comorbidities (not always significant)
• Was not associated with
• Gender
• Race/ethnicity
• Education (census track proxy)

8. Distribution of Treatment Intent
by Stage
Treatment Intent Stage III Stage IV
ADJUVANT 58.5% 8.1%
PALLIATIVE - FIRST LINE 1.4% 52.8%
CAPECITABINE (assumed Adjuvant
for stage III) 23.8% 19.9%
NEOADJUVANT 10.9% 4.3%
CURATIVE - FIRST LINE 4.8% 5.6%
Missing Treatment Intent 0.7% 6.8%
PALLIATIVE - AFTER FIRST LINE 0.0% 2.5%
P < .001

9. Distribution of Protocols
by Stage
Protocol Name Stage III Stage IV
ONCA COLORECTAL COLON FOLFOX-6
MODIFIED - ADJUVANT - PRL105 40.8% 23.0%
CAPECITABINE 23.8% 19.9%
ONCA COLORECTAL COLON FOLFOX-6
MODIFIED BEVACIZUMAB - PRL106 0.0% 32.9%
ONCA COLORECTAL RECTAL FLUOROURACIL
(CI) WITH RT - PRL103 11.6% 1.9%
ONCA COLORECTAL COLON CAPOX - PRL113 8.2% 1.9%
ONCA COLORECTAL COLON FLUOROURACIL
LEUCOVORIN (ROSWELL PARK) - PRL132 4.1% 3.1%
ONCA COLORECTAL COLON CAPOX
BEVACIZUMAB - PRL114 0.0% 6.2%
Other 11.6% 11.2%
P < .001

10. Distribution of First-Line Regimens
by Stage
Regimen Stage III Stage IV
FLUOROURACIL / LEUCOVORIN /
OXALIPLATIN 39.5% 31.1%
CAPECITABINE 23.8% 20.5%
BEVACIZUMAB / FLUOROURACIL /
LEUCOVORIN/ OXALIPLATIN 0.7% 23.6%
FLUOROURACIL 12.9% 1.2%
CAPECITABINE/ OXALIPLATIN 9.5% 3.1%
FLUOROURACIL / LEUCOVORIN 8.2% 3.1%
BEVACIZUMAB / CAPECITABINE /
OXALIPLATIN 0.0% 5.0%
Other 5.4% 12.4%
P < .001

11. Reasons for Discontinuation
by Stage
Reason Stage III Stage IV
Missing Reason for Discontinuation 40.8% 30.4%
Capecitabine 23.8% 19.9%
Progression of disease 2.7% 24.8%
Treatment plan completed 18.4% 7.5%
Toxicity from treatment 6.1% 5.6%
Patient/family preference 4.1% 4.3%
Maximal response 0.0% 3.7%
Other, please note reason in progress notes 1.4% 2.5%
Current part of multi-part regimen completed 2.0% 0.0%
Co-morbidity 0.0% 1.2%
P < .001

12. Results – Changes & Numbers
Stage III Stage IV
Mean (std) Mean (std)
Number of changes in treatment intent 0.8 (0.4) 0.8 (0.5)
Number of changes in protocol 0.8 (0.5) 0.9 (0.5)
Number of different drug regimens 1.1 (0.4) 1.4 (0.7)
Number of cycles of drug regimen 3.6 (3.0) 3.5 (2.6)

13. Cost Estimation by Regimen and Dose
Total AWP
Patient Total AWP Cost Per
example Cost Per Treatment
Chemotherapy Dose Units AWPCost Regimen Plan
A FLUOROURACIL - IVPB 2400 mg/m2/dose $ 27.99
FLUOROURACIL 648 mg $ 4.67
LEUCOVORIN 648 mg $ 38.88
OXALIPLATIN 137.7 mg $ 1,974.40 4 cycles
$2,045.94 $8,183.75
B BEVACIZUMAB 453.5 mg $ 3,247.65
FLUOROURACIL -IVPB 2400 mg/m2/dose $ 35.77
FLUOROURACIL 828 mg $ 5.96
LEUCOVORIN 828 mg $ 49.68
OXALIPLATIN 176 mg $ 2,523.56 2 cycles
$ 5,862.62 $11,725.24
C
XELODA TAB 500MG 100 caps $ 329.24 $ 3,292.37 $3,292.37

14. Summary of Results
• The distributions associated with treatment intent,
protocols, regimens, and reasons for discontinuation,
varied significantly by stage.
• The most common first line treatment was Oxaliplatin
+ Fluorouracil + Leucovorin.
• First-line oral chemotherapy agents (e.g capecitabine)
are not always captured in Beacon
• Missing observations are common for some variables
(e.g reason for discontinuation, treatment intent, etc)
• Costs of chemotherapy vary by both regimen and
dosage

15. Conclusions
Newly available VDW chemotherapy infusion
data derived from the EpicCare and Oncology
Beacon® files (along with other infusion data
sources) is a rich cancer treatment data
source that researchers can use to conduct
clinical- and policy-relevant comparative
effectiveness research studies in patients
with colorectal cancer.

16. Acknowledgements
This pilot project was directly funded by Kaiser Permanente and the
Center for Safety and Effectiveness Research (CESR). Indirect support and
support for preliminary analyses were provided by NCI Grant No. RC2
CA148185, Building CER Capacity: Aligning CRN, CMS, and State
Resources to Map Cancer Care, Co-PIs: Jane C. Weeks, MD and Debra P.
Ritzwoller, PhD, and NCI Cooperative Agreement No. U19 CA79689,
Increasing Effectiveness of Cancer Control Interventions (Cancer Research
Network), PI: Edward H. Wagner, MD.
pecial thanks to Drs. Jane Weeks and Deborah Schrag for their comments
and suggestions regarding the original study design.